Holding Healthcare Providers Accountable: Regulating Practitioners Through Medical Councils
Doctors in India are regulated by professional bodies at the state level through State Medical Councils (“SMCs”) and at the central level through the National Medical Commission (“NMC”). These authorities are obligated to maintain registers of qualified doctors and discipline them for unprofessional conduct. Based on an analysis of 30 SMC laws, information obtained through 94 RTI applications, and observations from 33 cases from Indian constitutional courts, our research suggests that these professional bodies are failing to perform their duties at several levels. We first examine the structure and functioning of the NMC, and we then proceed to examine the SMCs and their performance over the years.
Registration of Medical Practitioners
The National Medical Commission Act 2019 (“NMC Act 2019”) establishes four autonomous boards, one in particular being the Ethics and Medical Registration Board (“EMRB”). This Board is responsible for registering and regulating medical practitioners. The EMRB is mandated to maintain national registers of practitioners, make regulations to govern their professional conduct, and exercise appellate jurisdiction over the decisions taken by SMCs. However, the EMRB is currently operating with only two out of its sanctioned strength of five members, in addition to the position of President of the Board lying vacant.
Our research suggests that the registration system is uncoordinated and does not accurately reflect the number of doctors. There are stark discrepancies between the number of medical practitioners registered and listed in the Indian Medical Register and the numbers obtained through RTI applications in several states. Further, the EMRB is currently operating with only two out of its sanctioned strength of five members, in addition to the position of President of the Board lying vacant. Meanwhile, the process for setting up the National Register began four years after the enactment of the NMC Act 2019, and even now, the delay persists as the EMRB is yet to set up the web portal for practitioners to apply for registration.
The NMC Registration of Medical Practitioners and License to Practice Medicine Regulations 2023 made by the National Medical Commission also leave significant gaps. There are several ambiguities in the implementation of the provisions due to their drafting.
Most SMC laws follow a common structure. They set up the SMC, provide for the appointment of the Registrar, lay down the registration procedure for doctors, and empower the Councils to refuse, suspend, or cancel registrations. Many of these laws establish bodies representing the interests of doctors, and none of the SMCs have any representation from patients’ groups, local bodies, private sector associations like chambers of commerce, or consumer groups.
Several SMC laws remain unenforced. Four states do not have functional SMCs and several operational SMCs do not maintain or regularly update records of registration. Notably, we observed stark discrepancies between the number of RMPs recorded in the Indian Medical Register and the number obtained from SMCs through RTI applications.
Disciplinary Action Against Registered Medical Practitioners
The SMC’s role in disciplining registered medical practitioners (“RMPs”) for misconduct is important because the alternative judicial remedies are time-consuming and expensive for patients. All the SMC Acts confer wide powers on the council to take disciplinary action, but the legislation of only seven states/union territories permit an aggrieved person to file a complaint against an RMP for professional misconduct. While all SMC laws empower the SMC to remove an RMP from the register and impose fines, some permit the SMC to award imprisonment as well. Some SMC Acts also empower the SMC to award compensation to the aggrieved.
However, SMCs fail to perform their adjudicatory functions effectively. Very few complaints are instituted, and even when instituted, the most common disciplinary actions are warnings or mandating attendance of continuing medical education (CME), with very few instances of an RMP being removed from the register either temporarily or permanently. From information obtained through two SMCs – Karnataka and Uttarakhand – we observe similar trends. SMCs prefer issuing warnings over all other disciplinary measures. Occasionally, they direct that the practitioner provide affidavits or undertake CME, and they rarely order suspension of registration. Interestingly, these two SMCs sanctioned clinical establishments in some instances as well, even when they are not legally empowered to govern establishments.
Moreover, the procedure for appealing orders of SMCs is ambiguous. The NMC Act 2019 and several SMC Acts establish parallel appellate mechanisms with no clarity about which mechanism would prevail over the others. The NMC Act 2019 establishes that the first appeal would lie before the EMRB and the second appeal before the NMC. On the other hand, State Acts allow appeals against decisions of the SMC before the state government. As medical practitioners may practise in more than one state, stipulating the State Government as an appellate authority may not be suitable.
The NMC Professional Conduct Regulations 2023 (currently in abeyance) indicate that states are expected to establish an online grievance redressal system. However, the goal of an accessible and effective grievance redressal mechanism through SMCs is distant. Four SMCs do not have operational websites. Seventeen SMC websites provide no information about complaint processes. Only four SMCs have an online portal for filing complaints.
We recommend that the NMC Act and regulations made under it as well as the various SMC Acts be amended to clarify existing ambiguities, that all medical councils maintain operational websites and publish their respective State Medical Registers in a machine-readable and searchable format, and mandatorily provide an online mechanism for the public to file complaints against RMPs. Additionally, a live dashboard must be established and maintained real-time to track the number of complaints registered and disposed of by each SMC. Members of SMCs should be sensitised and trained on the law and practice of disciplinary proceedings to ensure an equitable and fair procedure.